Comparison of laparoscopic manual suturing and laparoscopic stapler usage for gallbladder duodenal fistula stoma closure

Abstract

Background

Cholecystoduodenal fistula (CDF) is a rare complication of recurrent gallstone disease, characterized by chronic inflammation, localized ischemia, and tissue necrosis. In this study, the clinical outcomes associated with laparoscopic manual suturing and stapler-assisted closure were compared in the context of CDF repair with accompanying video presentations.

Methods

Overall, 21 patients diagnosed with CDF who underwent treatment at Fujian Provincial Hospital between January 2010 and December 2024 were retrospectively analyzed. Participants were categorized into two groups: those who underwent stapler-assisted closure (stapler group, n = 12) and those who underwent manual suturing (manual suture group, n = 9). Intraoperative parameters, postoperative recovery markers, and complication rates were compared between groups. Statistical data were evaluated using SPSS version 26.0 (SPSS Inc., IL, USA) and p < 0.05 was considered as significant in all analyses.

Results

The patient characteristics and preoperative factors were similar in two groups (p > 0.05). The stapler group had a significantly shorter operative time in comparison with the manual suture group (72.5 min vs. 115.0 min, p < 0.001) and four patients (44.4%) in the manual suture group required conversion to open surgery (p:0.021). Subtotal cholecystectomy was performed in 5 patients (41.7%) in stapler group, and 3 patients (33.3%) in manual suture group. The sizes of the cholecystoduodenal fistulas were almost same between two groups (0.8 cm vs. 0.7 cm). Postoperative complications were mostly seen in manual suture group; 3 patients (33.3%) had duodenal fistula and 2 patients (22.2%) required reoperation. Postoperative recovery occurred more rapidly in the stapler group, with a shorter period to start to oral intake, for removal of nasogastric and drainage tubes; and a shorter duration of hospitalization time (p < 0.05).

Conclusion

Laparoscopic stapler-assisted repair of CDF using the preserved gallbladder wall offers significant advantages over traditional manual suturing. It decreases the operative duration, lowers conversion rates, and reduces the odds of postoperative complications. Given these benefits, this technique is recommended for broader clinical adoption. However, in cases where the stapler use is inappropriate due to the technical issues; manual suturing can be the preferable method in selected cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-026-03585-w.

Introduction

Cholecystoduodenal fistula (CDF) is an uncommon complication of chronic gallstone disease [1], which is resulted by the persistent pressure of the duodenal wall leading to fistula formation by localized ischemia and necrosis. Accounting for approximately 80% of all cholecystoenteric fistulas, CDF is the most frequently encountered variant [2, 3]. The clinical presentation of CDF is often nonspecific, with symptoms that include right upper quadrant pain, fever, abdominal distension, and vomiting. Only 1%−3% of cases, gallstones may migrate through the fistula into the duodenum and potentially cause to gastric outlet obstruction, a condition referred to as Bouveret syndrome [4–9].

The prolonged persistence of CDF can lead to severe complications which can include gallstone ileus, intestinal perforation, bowel necrosis, and even gallbladder carcinoma [10–13]. Thus, surgical intervention is necessary [1, 14] and the standard surgical approach involves open cholecystectomy with direct duodenal fistula closure. Recent advances in laparoscopic techniques gave rise to implementation of minimally invasive techniques [15, 16]. However, laparoscopic CDF repair still remains challenging owing to chronic inflammation and extensive tissue adhesions; and results to conversion to open surgery with an incidence of 70% [17]. Even in open procedures, duodenal fistula-related complications occur in ~ 17.5% of patients due to weakened and prolonged process of healing [18].

To mitigate the risk of postoperative duodenal fistula, some studies have suggested preserving a portion of the gallbladder wall to facilitate the closure and potentially reduce the disruption of the duodenal wall during suturing [19]. The limited ability of suturing capabilities in laparoscopy and the increased risk of fragile tissues by the way of severe inflammation and edema of gallbladder; a higher risk for the integrity of the closure can occur; and make the manual suturing technique more prone to postoperative complications [20]. Furthermore, laparoscopic suturing demands advanced surgical expertise which is depending on the abilities of the surgeon. To address these difficulties, this surgical technique was herein modified by utilizing an Endo-GIA stapler to close the preserved gallbladder wall, thereby minimizing the risks to achieve more favorable clinical outcomes. The present study details the technical modifications implemented for this approach and compares the outcomes associated with these two laparoscopic approaches for CDF repair.

Methods

Design of the study and data collection

A retrospective analysis was performed using the data of patients diagnosed as CDF whom underwent laparoscopic surgery at Fujian Provincial Hospital between January 2010 and December 2024. The inclusion criteria of the patients in the study were (1) preoperatively or intraoperatively confirmation of CDF; (2) gallbladder wall preservation at the fistula site during the surgery to enable direct suturing; (3) gallbladder wall preservation at the fistula site with Endo-GIA stapler-based closure. The exclusion criteria of the study were (1) the requirement for duodenostomy or gastrojejunostomy during the first operation; and (2) the presence of gallbladder malignancy. Experienced hepatobiliary surgeons on laparoscopy performed all procedures in this study. Ethical approval was obtained from the Fujian Provincial Hospital Ethics Committee in accordance with the latest version of the Declaration of Helsinki (Ethics Approval Number: K2025-09–011).

The data for this study consisted of baseline characteristics of patients including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and accompanying comorbidities of patients (e.g., diabetes mellitus, hypertension, prior abdominal surgeries). In addition, a series of intraoperative variables like operation time, intraoperative blood loss, size of fistula formation, and the rate of conversion to open surgery were assessed. Postoperative complications included the assessment of intra-abdominal and pulmonary infections, the status of hemorrhagy, paralytic ileus and formation of duodenal fistula (Within 30 days postoperatively, CT or upper gastrointestinal contrast study showed extravasation of contrast medium from the duodenal fistula); and all were evaluated as overall and major complications (Clavien-Dindo Classification III–V) [21]. Regarding the postoperative outcomes; the need for re-operation, admission to ICU, and in-hospital mortality were determined. Postoperative recovery markers like time to intake of semifluid diet, time to first flatus, nasogastric tube removal (daily drainage < 100 mL), drainage tube removal (cessation of drainage within one week), and median postoperative length of stay (PLOS) were assessed. All conversions to open surgery were included in the intention-to-treat analysis and analyzed according to the original assigned group. Operative time for converted cases included the total time from initiation of laparoscopy to completion of the open procedure.

Preoperative evaluation of patients

All patients presented with recurrent right upper abdominal pain and underwent hematological and imaging examinations following the hospital admission. If the patients do not have acute attacks of cholecystitis meanwhile, definitive surgical treatment was performed during the same hospitalization. For patients with symptoms of acute cholecystitis, antibiotherapy was initiated; and percutaneous transhepatic gallbladder drainage (PTGD) was performed when the findings on imaging persist with clinical symptoms. In cases of duodenal obstruction caused by impacted gallstones; endoscopic lithotripsy and stone extraction were performed and surgery was planned approximately after two months by evaluation of repeated magnetic resonance imaging (MRI) and/or computed tomography (CT) findings regarding the control of inflammation. Definitive surgical intervention was carried out if no signs of hyperemia or edema of the gallbladder or adjacent intestinal wall were observed. In both patient groups, there were no patients with bile duct stones preoperatively, therefore, ERCP was not required. Detailed preoperative MRI/CT findings of the patients are presented in Table 1.

Table 1.

Patient characteristics

Characteristic	Stapler group(n = 12)	Manual suture Group(n = 9)	p
Age, median[IQR], y	56.5(50.0 ~ 61.8)	54.0(48.5 ~ 66.5)	0.859
Gender, n (%)			1.000
Male	5(41.7)	4(44.4)
Female	7(58.3)	5(55.6)
BMI, median[IQR]	22.4(22.3 ~ 24.6)	24.4(22.2 ~ 26.5)	0.319
ASA class, n (%)			0.842
I	7(58.3)	4(44.4)
II	3(25.0)	2(22.2)
III	2(16.7)	3(33.3)
Diabetes mellitus, n (%)	3(25.0)	2(22.2)	1.000
Hypertension, n (%)	3(25.0)	2(22.2)	1.000
PTGD, n (%)	1(8.3)	1(11.1)	1.000
Cholecystitis, n (%)	8(66.7)	6(66.7)	1.000
Previous abdominal surgery, n (%)	4(33.3)	3(33.3)	1.000
Liver function parameters
ALT, U/L	27.0 (24.0 ~ 30.0)	25.0 (23.0 ~ 28.0)	0.615
AST, U/L	27.3 (24.1 ~ 30.4)	27.4 (25.6 ~ 30.3)	0.569
ALP, U/L	93.0 (86.5 ~ 99.5)	93.5 (89.3 ~ 97.8)	0.831
GGT, U/L	41.4 (35.4 ~ 68.1)	43.5 (36.8 ~ 85.5)	0.522
TBil, µmol/L	13.1 (12.3 ~ 13.9)	13.1(12.2 ~ 14.2)	0.772
Inflammatory markers
WBC, ×10⁹/L	6.10(5.60 ~ 6.6)	6.40(5.8 ~ 7.0)	0.197
NEUT, %	65.9 (63.0 ~ 68.7)	63.8 (60.3 ~ 70.3)	0.497
CRP, mg/L	12.4 (8.6–18.7)	14.1 (9.3–21.5)	0.412

IQR Interquartile range, BMI Body mass index, ASA American Society of Anesthesiologists, PTGD Percutaneous Transhepatic Gallbladder Drainage, ALT Alanine aminotransferase, AST Aspartate aminotransferase, ALP Alkaline phosphatase, GGT Gamma-glutamyl transferase, TBil Total bilirubin, WBC White blood cell count, NEUT% Neutrophil percentage, MRI Magnetic resonance imaging

Details of the surgical approaches

All surgical procedures were conducted under general anesthesia with endotracheal intubation by experienced hepatobiliary laparoscopic surgeons. A four-port technique was employed; a 12 mm observation port beneath the umbilicus, a 12 mm main operating port beneath the xiphoid process, a 5 mm port at the right midclavicular line below the costal margin, and another 5 mm port at the right anterior axillary line beneath the costal margin (Fig. 1).The choice of surgical approach was made according to the surgeon’s operating habits; however, manual suturing was employed in cases where the preserved gallbladder wall was insufficient for secure closure with a stapler.

Fig. 1.

The trocar position

1. Gallbladder Management: An incision was made in the gallbladder along the fundus by preserving as much wall as possible at the duodenal attachment, and this attachment was used as a biological patch to repair the duodenal fistula (Fig. 2A). Gallstones were fully extracted (Fig. 2B). Calot’s triangle was carefully dissected to identify the cystic duct and artery, and after they were subsequently ligated and transected, and the gallbladder was then removed (Fig. 2F). In cases where severe inflammation hindered safe dissection, the transection of the gallbladder was performed at the infundibulum and closed with absorbable sutures after extraction of stones (Fig. 2C). The liver-adjacent gallbladder wall was either excised or its mucosa ablated using electrocautery.

2. Duodenal Fistula Closure: In stapler group, the preserved gallbladder wall was lifted and approximated, and then closed using an Endo-GIA stapler (Johnson & Johnson Endo-GIA™ Universal Stapler, 45-mm length, white cartridge). The stapler line spacing was 3.5 mm, and the knife blade height was 1.0 mm. Ethicon Endo-Surgery, Cincinnati, OH, USA) (Figure 2D) (Video 1). For larger fistulas; stapling was performed perpendicularly to the duodenum’s long axis. In manual suture group, a 3-0 absorbable suture material was used for continuous suturing and knotting across the preserved gallbladder wall for complete closure (Figure 2E) (Video 2).

3. Nasogastric and Abdominal Drain Placement: A nasogastric tube was inserted after closure of CDF, and methylene blue was injected to confirm the absence of leakage. An abdominal drainage tube was positioned at the foramen of Winslow.

Fig. 2.

Closure of the gallbladder-duodenal fistula stoma using manual suturing and a laparoscopic stapler. A The gallbladder was incised, preserving the portion of the wall that had fused with the duodenum. B Complete removal of gallstones from the gallbladder cavity. C Suturing of the cystic duct. D Closure of the preserved gallbladder wall with an Endo-GIA stapler. E Suturing of the preserved gallbladder wall. F Gallbladder removal

Follow-up procedure

All patients received short-term follow-up (< 90 days). Prophylactic cefuroxime was administered for 2 days after surgery and abdominal ultrasound was performed routinely to check the intraabdominal fluid collection or any leakage after surgery. If patients had postoperative duodenal fistula, broad-spectrum antibiotics and follow-up protocols of intraabdominal drainage were implemented to gain spontaneous healing. If the fistula persists or progresses, second operation was considered for repair of stoma closure or forming an anastomosis. All postoperative complications or any hospital readmissions within 90 days after discharge were recorded (Table 1).

Statistical analysis

Statistical analyses were conducted using SPSS version 26.0 (SPSS Inc., IL, USA). Continuous variables that were distributed normally were expressed as mean ± standard deviation (SD), whereas non-normally distributed data are instead given as the median and interquartile range (IQR). Comparisons of parametric continuous variables between groups were performed using an independent sample t-test, while non-parametric variables were analyzed using the Mann-Whitney U test. Categorical variables were reported as counts and percentages and assessed using either the chi-square (χ²) test or Fischer’s exact test, as appropriate. p < 0.05 was considered as significant in all analysis.

Results

Baseline characteristics

A total of 21 patients met the inclusion criteria, with 12 assigned to the stapler group and 9 to the manual suture group. No statistically significant differences were observed between the groups with respect to age, sex, BMI, diabetes history, ASA score, hypertension, previous cholecystitis attacks, prior abdominal surgeries and the necessity for preoperative percutaneous transhepatic gallbladder drainage (PTGD) (p > 0.05). The background comorbidities and history for prior abdominal surgeries were present in both groups. Regarding preoperative serum biochemical and inflammatory markers, serum leucocytosis (6.10 × 10⁹/L vs. 6.40 × 10⁹/L, p: 0.197), neutrophil percentages (65.9% vs. 63.8%, p: 0.497) were similar; and serum CRP levels were also comparable (12.4 mg/L vs. 14.1 mg/L, p: 0.412) between the stapler and manual suture groups.

Intraoperative outcomes

Intraoperative findings provided confirmation of the presence of the cholecystoduodenal fistula (gallbladder-duodenal fistula) for all of the patients in this study. The mean fistula diameter and intraoperative blood loss were not significantly different between the stapler and manual suture groups (0.8 cm vs. 0.7 cm, p: 0.540) (30 mL vs. 30 mL, p: 0.821) The stapler group exhibited a significantly shorter operative time compared to the manual suture group (72.5 min vs. 115.0 min, p < 0.001). In the stapler group 5 patients (41.7%), and in the manual suture group 3 patients (33.3%) underwent subtotal cholecystectomy due to severe inflammation in Calot’s triangle (p > 0.05). Only four patients (44.4%) in the manual suture group required to conversion to open surgery due to the enlargement of the fistula during suturing, severe adhesions, inadequate closure of the fistula, or limited laparoscopic visibility impeding precise needle implementation (p:0.021). A comprehensive summary of intraoperative parameters is provided in Tables 2 and 1.

Table 2.

Intraoperative outcomes

Characteristic	Stapler group(n = 12)	Manual suture Group(n = 9)	p
Total operative time, median[IQR], min	72.5(68.5 ~ 83.8)	115.0(102.5 ~ 167.5)	< 0.001
Total blood loss, median[IQR], ml	30.0(20 ~ 50)	30.0(20 ~ 50)	0.821
Subtotal cholecystectomy, n (%)	5(41.7)	3(33.3)	1.000
Size of fistula[IQR], cm	0.8(0.5 ~ 1.0)	0.7(0.6 ~ 0.9)	0.540
Conversion, n (%)	0(0.0)	4(44.4)	0.021

IQR Interquartile range

Postoperative outcomes

In the stapler group, only one patient (8.3%) experienced postoperative complications. This patient had undergone a standard cholecystectomy and developed high fever on postoperative day 1 with growth of enterococcus faecium in serum blood culture, and it was considered as postoperative ascending cholangitis due to the procedure. The patient recovered within one week following treatment with broad-spectrum antibiotics, and the complication was neither severe nor associated with duodenal fistula formation.

In contrast, the manual suture group had four patients (44.4%) with postoperative complications. One patient who underwent conversion to open surgery and subtotal cholecystectomy developed high postoperative fever on postoperative day 1 with growth of enterococcus faecium in serum blood culture, and it was considered as postoperative ascending cholangitis and patient recovered within one week following treatment with broad-spectrum antibiotics. In addition, three patients (33.3%) developed duodenal fistulas, and two of them (22.2%) experienced severe complications (Clavien–Dindo grade ≥ III). Among these three cases; one patient had clinically controllable postoperative leakage and; spontaneous healing occurred by antibiotics and daily follow-up with drainage catheters in 14 days. Two other cases required reoperations and ICU admission due to severe complications. One of them had signs of septic shock on postoperative 13th day and required re-operation for replacement of double-drainage catheters to provide effective continuous abdominal lavage and drainage along with broad-spectrum antibiotics. Patient was followed in intensive care and aon postoperative 39th day, the upcoming content diminished, fistula healed and recovery of patient was observed. The last patient who had a history of common bile duct exploration had duodenal fistula on postoperative 3th day. After the daily output of 400–500 ml content with sypmtoms of fever and abdominal distension, enterocutaneous fistula developed and patient underwent open gastrojejunostomy. After formation of gastrojejunostomy, the daily output of drainage decreased to 50–100 ml per day but with a purulent and hemorrhagic content. On postoperative 3rd month, patient had massive upper gastrointestinal bleeding which was possibly due to the formation of visceral pseudoaneurysm resulting from prolonged inflammation related with fistula and massive upper gastrointestinal bleeding resulted with mortality (Table 4).

Table 4.

The details of patients

Patient no.	group	Age (year)	Sex	Past medical history	Preoperative magnetic resonance imaging (MRI)/computed tomography (CT)	Size of fistula(cm)	Intraoperation	Postoperative treatment
1	Stapler	58	Male	Hypertension/Diabetes	Gallbladder wall thickening and inflammatory changes in the adjacent duodenum, with a fistulous tract identified between the gallbladder and the duodenum	0.8	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
2	Stapler	62	Female	Diabetes/Colon surgery	Cholecystoduodenal fistula, accompanied by gallbladder atrophy and postoperative changes following PTGD	0.5	Cholecystectomy	No postoperative fistula/On postoperative day 1, the patient developed a fever of 38.5 °C. No drainage was observed from the abdominal drain. Abdominal CT showed no intra-abdominal fluid collection. Blood cultures grew Enterococcus faecium. The patient received piperacillin–tazobactam for 1 week, and the fever resolved without recurrent attacks.
3	Stapler	55	Female	No	Pericholecystic inflammatory exudation, gallbladder atrophy with wall thickening, and the presence of a cholecystoduodenal fistula	0.7	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
4	Stapler	68	Female	Chronic obstructive pulmonary disease/Hypertension	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula	0.5	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
5	Stapler	78	Male	Hypertension/Diabetes/Coronary Heart Disease	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula	1.0	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
6	Stapler	49	Male	No	Gallbladder atrophy with thickening of the gallbladder wall and the adjacent duodenal wall, and the presence of a cholecystoduodenal fistula.	0.5	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
7	Stapler	61	Female	Cervical cancer surgery	Cholecystoduodenal fistula.	0.9	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
8	Stapler	54	Male	Interstitial Pneumonia	Gallbladder atrophy, cholecystoduodenal fistula, and mild pericholecystic inflammatory changes.	0.8	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
9	Stapler	44	Female	Caesarean section	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula, and low confluence of the right and left hepatic ducts.	1.0	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
10	Stapler	60	Female	Chronic Renal Insufficiency G1	Thickening of the gallbladder wall and the adjacent duodenal wall, with mild pericholecystic inflammatory exudation, and the presence of a cholecystoduodenal fistula.	1.2	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
11	Stapler	53	Female	Caesarean section	Cholecystoduodenal fistula.	0.6	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
12	Stapler	48	Male	No	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula	0.9	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
13	Manual suture	71	Male	Hypertension/Diabetes/Diabetic Nephropathy/Chronic Renal Insufficiency G4/Common bile duct exploration	Thickening of the gallbladder wall and the adjacent duodenal wall, with mild surrounding inflammatory exudative changes, and the presence of a cholecystoduodenal fistula.	1.0	Conversion/The fistula in the duodenum enlarged due to the suture cutting through the intestinal wall tissue during closure.	Fistula/Reoperation/Died due to massive gastrointestinal bleeding/On postoperative day 3, the abdominal drainage tube began to drain dark green and gray-brown duodenal fluid, with a daily volume of approximately 400–500 ml, accompanied by fever and abdominal distension. The patient was treated with cefoperazone-sulbactam for infection, and the fever and distension improved. On postoperative day 5, wound infection was noted, and the incision was found to communicate with the abdominal cavity, resulting in leakage of digestive fluid through the incision, with a daily volume of about 200–300 ml. Therefore, an additional drainage tube was inserted through the incision into the abdominal cavity. After active wound care, the incision gradually healed, but an enterocutaneous fistula developed, with a daily output of approximately 500–800 ml of intestinal fluid, which caused erosion of the surrounding skin. On postoperative day 82, abdominal infection worsened, accompanied by high fever. Meropenem was administered antibiotherapy, but no improvement was observed. A second operation for gastrojejunostomy was performed. After surgery, the patient was admitted to the ICU and treated with vancomycin for infection control. Postoperatively, the abdominal drainage tube drained 50–100 ml of purulent and hemorrhagic outcome per day, and infection markers decreased in comparison with preoperative levels. However, on postoperative day 97, the patient suddenly developed massive upper gastrointestinal bleeding and died.
14	Manual suture	45	Male	Appendectomy	Cholecystoduodenal fistula.	0.6	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
15	Manual suture	47	Female	No	Gallbladder atrophy with wall thickening, postoperative changes following PTGD, and formation of a cholecystoduodenal fistula.	0.7	Cholecystectomy	Fistula/Spontaneous healing with drainage/The drainage fluid, identified as intestinal content, cultured Escherichia coli, for which the patient received antibiotherapy with cefoperazone–sulbactam. The patient was managed with fasting and gastrointestinal decompression. The daily drainage output was about 100 ml, which gradually decreased; by postoperative day 8 no drainage fluid was observed, and the drain was removed on postoperative day 14.
16	Manual suture	50	Female	No	Gallbladder atrophy with thickening of the gallbladder wall and the adjacent duodenal wall, and the presence of a cholecystoduodenal fistula.	0.5	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
17	Manual suture	62	Male	Rheumatic Heart Disease/Rheumatoid Arthritis	Thickening of the gallbladder wall, cholecystoduodenal fistula, and low insertion of the cystic duct.	0.8	Conversion/After suturing, a small amount of methylene blue still leaked from the fistula when injected through the gastric tube.	Fistula/Reoperation/Healed after double-catheter lavage/Postoperatively, daily drainage of 50–100 ml of grayish-brown fluid was observed, accompanied by symptoms of abdominal distension and fever. Imaging revealed intra-abdominal effusion, and ultrasound-guided puncture and catheter drainage were unsatisfactory, yielding only about 30 ml/day of grayish-brown fluid. The patient was treated with meropenem, gastrointestinal decompression, but intra-abdominal infection and paralytic ileus showed no significant improvement. On postoperative day 13, the patient developed septic shock, requiring reoperation with the placement of double catheters for abdominal lavage and drainage. The patient was transferred to the ICU, where continuous abdominal lavage was performed via the double catheters, along with continued meropenem therapy. Fever and abdominal distension gradually improved. The lavage fluid changed from grayish-brown to clear. On postoperative day 20, abdominal lavage was discontinued, and daily drainage consisted of 30–50 ml of light yellow fluid. By postoperative day 39, no drainage fluid was observed, and the drain was removed.
18	Manual suture	53	Female	Diabetes	Gallbladder atrophy with thickening of the gallbladder wall and the adjacent duodenal wall, and the presence of a cholecystoduodenal fistula.	0.8	Cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
19	Manual suture	57	Female	Caesarean section	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula	0.9	Conversion/Subtotal cholecystectomy/Severe adhesions	No postoperative fistula/On postoperative day 1, the patient developed a fever of 40 °C. Blood cultures grew Enterococcus faecium. Abdominal CT showed no residual gallbladder or common bile duct stones, no intra-abdominal fluid collection, partial right lung atelectasis, and a small amount of pleural effusion. The patient received piperacillin–tazobactam for 1 week, and the fever resolved without recurrence.
20	Manual suture	54	Female	No	Gallbladder wall thickening, mild pericholecystic inflammatory changes, cholecystoduodenal fistula	0.7	Subtotal cholecystectomy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.
21	Manual suture	82	Male	Hypertension/Coronary Heart Disease	Gallbladder atrophy, cholecystoduodenal fistula, and mild pericholecystic inflammatory changes.	0.5	Conversion/Poor visualization of the duodenal fistula under endoscopy	No postoperative fistula/Prophylactic cefuroxime was administered for 2 days after surgery, and abdominal ultrasound was performed to monitor for intra-abdominal fluid collection.

Postoperative recovery was significantly faster in the stapler group, with shorter times to first flatus (p: 0.002), initiation of a semifluid diet (p: 0.002), removal of the nasogastric tube (p: 0.004), drainage tube removal (p: 0.005), and hospital discharge (p: 0.008) (Tables 3 and 4).

Table 3.

Postoperative outcomes

Characteristic	Stapler group(n = 12)	Manual suture Group(n = 9)	p
Overall complications, n (%)	1(8.3)	4(44.4)	0.119
Major complication, n(%)	0(0.0)	2(22.2)	0.171
Bile leak, n (%)	0(0.0)	0(0.0)	1.000
Duodenal fistula, n (%)	0(0.0)	3(33.3)	0.063
Postoperative hemorrhage, n (%)	0(0.0)	1(11.1)	0.429
Intra-abdominal infection, n (%)	0(0.0)	2(22.2)	0.171
Pulmonary infection, n (%)	1(8.3)	3(33.3)	0.272
Septic shock, n (%)	0(0.0)	2(22.2)	0.171
Paralytic ileus, n (%)	0(0.0)	1(11.1)	0.429
Reoperation, n (%)	0(0.0)	2(22.2)	0.171
ICU admission, n (%)	0(0.0)	2(22.2)	0.171
Mortality, n (%)	0(0.0)	1(11.1)	0.429
Anus exhausting time [IQR], day	3.0(2.0 ~ 3.0)	4.0(3.0 ~ 8.0)	0.002
Time for semifluid dieting [IQR], day	4.0(4.0 ~ 5.0)	6.0(5.0 ~ 12.0)	0.002
Nasogastric tube removal time, median[IQR], day	3.0(3.0 ~ 4.0)	4.0(4.0 ~ 14.5)	0.004
Drainage removal time, median[IQR], day	7.0(7.0 ~ 8.0)	9.0(8.0 ~ 26.5)	0.005
PLOS, median[IQR], day	9.0(9.0 ~ 10.0)	12.0(10.0 ~ 30.5)	0.008

IQR Interquartile range, ICU Intensive Care Unit, PLOS Post operative length of stay

Follow up outcomes

All enrolled patients underwent postoperative follow-up. Scheduled follow-up visits were conducted at postoperative day 30 and day 90, including abdominal CT reassessment to evaluate for residual stones, or symptoms of cholangitis. In addition, patients were instructed to return to the hospital at any time if they developed symptoms suggestive of cholangitis during the follow-up period and no residual stones were identified in any patient. One patient in the stapler group developed cholangitis 63 days after discharge and recovered following a 5-day course of broad-spectrum antibiotics during readmission. One patient in the manual suture group developed cholangitis 35 days after discharge and improved after 7 days of broad-spectrum antibiotic therapy during hospitalization. Both patients had previously undergone subtotal cholecystectomy.

Discussion

CDF is an uncommon but potentially severe condition which can lead to severe complications like intestinal obstruction, biliary tract infections, perforation of the duodenum and; can cause to increased risk for gallbladder or bile duct malignancies [22, 23]. The standard treatment strategy involves cholecystectomy with duodenal fistula repair [24]. This approach involves complete excision of the gallbladder together with the surrounding scar tissue, with subsequent direct duodenal wall suturing to close the fistula. However, this approach carries substantial risks, including inadvertent fistula enlargement during dissection, damage to adjacent structures such as the common bile duct or colon, and postoperative duodenal stenosis due to direct closure [25]. To address these challenges, some studies have suggested preserving a portion of the gallbladder wall to serve as a patch for fistula repair [19]. However, laparoscopic suturing remains technically demanding, as the fixed angulation of laparoscopic instruments poses limitations, especially in access to the duodenal wall for repair of the fistula. This difficulty is further exacerbated for fistulas located near the posterior duodenal wall [20]. The adoption of a linear cutting stapler offers an alternative approach, by providing adjustable angulation, consistent closure strength, and improved technical feasibility, particularly in minimally invasive surgery [26–28]. In this study, we implemented the surgical technique by using a linear cutting stapler for gallbladder wall closure and compared its clinical effectiveness with manual suturing.

Patients with CDF frequently present with extensive adhesions, gallbladder atrophy, and edematous tissues due to chronic inflammation. Attempting to perform complete anatomical dissection in such cases may increase the risk of iatrogenic injury to surrounding structures and may also enlarge the duodenal fistula due to tissue tearing. To reduce these risks, our approach involves incising the gallbladder along its bed while preserving as much gallbladder wall as possible at the fistula–duodenum interface. This preserved gallbladder wall is then used as a biological patch for fistula repair. When the anatomy of Calot’s triangle can be clearly identified, we use the conventional method of individually ligating and dividing the cystic duct and cystic artery, followed by removal of the residual gallbladder wall on the hepatic side. In cases where severe inflammatory adhesions prevent safe exposure of Calot’s triangle, subtotal cholecystectomy is performed to avoid bile duct injury. This procedure has been widely recognized as a safe and effective technique for managing complex gallbladder diseases [29–32]. When the anatomy of Calot’s triangle was clearly identified and no residual stones were present, the cystic duct was confirmed to be stone-free and the gallbladder infundibulum was closed using sutures. The residual gallbladder wall on the hepatic bed was then treated either by mucosal ablation with electrocautery or by complete excision. However, subtotal cholecystectomy carries certain postoperative risks, including bile leakage, infection, retained cystic duct stones, residual cholecystitis, and stone recurrence.Therefore, the procedure should be selected cautiously. Notably, in our study, one patient who underwent subtotal cholecystectomy developed high fever and bacteremia postoperatively. We speculate that, after subtotal resection, the reduced volume of the gallbladder remnant may have increased intraluminal pressure, facilitating bacterial entry into the bloodstream.

The present analyses compared intraoperative outcomes between groups treated using manual and stapler-based approaches, highlighting the advantages of using a stapler in CDF repair. The results suggested that stapler-assisted closure could reduced operative time and decreased the rate of intraoperative conversion to open surgery. The superiority of the linear cutting stapler stems from its user-friendly design, adjustable head angle, and greater flexibility in closure angles, which collectively simplify the closure of the preserved gallbladder wall compared to manual suturing. Previous studies have shown that laparoscopic suturing in the gallbladder bed on right upper quadrant towards thoraco-abdominal cavity presents challenges due to restricted working space and limited suture angles, which can lead to uneven suture tension and tissue tearing, particularly in cases of acute inflammation with severe tissue edema. These factors contribute to an intraoperative conversion rate of nearly 50% in such cases [17, 33]. Three of the patients enrolled in the manual suture group necessitated conversion to open surgery due to the complexity of fistula location, tissue fragility, and severe intraoperative adhesions. One of these patients experienced gallbladder wall tearing during suturing, necessitating additional excision of the torn tissue along with the surrounding duodenal scar tissue. This process enlarged the fistula, increasing the risk of failure for implementation of laparoscopic closure and ultimately led to conversion. In contrast, none of the patients in the stapler group necessitated conversion to open surgery. The usage of stapler facilitates pre-closure compression of the gallbladder wall, and ensures optimal tissue approximation. Furthermore, its stable activation mechanism minimizes the risk of disruption of edematous tissues, enabling a precise, single-step preserved gallbladder wall closure. Previous studies have also demonstrated that stapler-assisted closure in the context of laparoscopic cholecystectomy for the management of acute cholecystitis effectively seals tissue and reduces the risk of postoperative bile leakage [34–36].

Postoperative outcomes also demonstrated patients in the stapler group exhibited significantly faster recovery times, including shorter durations for anal exhaust, transition to a semi-fluid diet, nasogastric tube removal, drainage tube removal, and overall hospital stay (p < 0.05). Similar results were also reported by Li et al. [37] This suggests that the use of Endo-GIA may contribute to accelerated postoperative recovery. Despite the less number of cases in the study, the reduced risk of postoperative complications were seen in stapler group (8.3% vs. 33.3%). In the stapler group, a single patient experienced ascending cholangitis, and they did not exhibit duodenal fistula formation. Conversely, all three postoperative complications in the manual suture group consisted of the formation of duodenal fistulas. Of these cases, one patient who did not necessitate conversion to open surgery recovered following fasting, gastrointestinal decompression, and adequate drainage. However, the other two cases involved severe intra-abdominal infections requiring reoperation, and both patients required postoperative ICU admission.

We also observed that not all CDF patients are suitable candidates for linear cutting stapler repair. Because the closure span of the stapler (approximately 45 mm for the Endo-GIA 45-mm cartridge) requires an adequate length and thickness of preserved gallbladder wall as the tissue platform. The stapler closure is feasible only when the gallbladder wall remains relatively intact and has not undergone to significant atrophy. In these cases, sufficient gallbladder wall can be retained to meet the stapler’s closure width, allowing the stapler to provide a rapid, stable, and uniform closure while reducing the technical difficulty. Similarly, in patients with severe gallbladder atrophy or chronic recurrent inflammation, the gallbladder wall becomes thin and fragile, making it impossible to preserve enough tissue to meet the stapler’s closure span. Attempting stapler closure in such cases may increase the risk of insecure closure or disruption of the tissue, therefore manual suturing should be performed instead. The higher incidence of postoperative duodenal fistula observed in the manual suture group in this study may be associated with a smaller amount of retained gallbladder wall used for repair, more severe tissue inflammation, poorer healing capacity, and variability in suturing technique among surgeons. These findings are consistent with the experience reported by Soto et al. [38].

Some researchers have suggested the reinforcement using an omental patch in patients with a high risk of postoperative duodenal fistula. Based on our findings, we recommend that stapler repair can be applied to patients with relatively preserved gallbladder wall and having sufficient tissue for stapler closure. Manual suturing should be reserved for cases with severe gallbladder atrophy, thin or fragile gallbladder wall, or insufficient remaining tissue for stapler application; however, this technique requires high suturing proficiency. For these patients, reinforcement with an omental patch over the repair site may be considered when necessary.

Postoperative complications are relatively common in patients with cholecystoduodenal fistula (CDF). Based on our experience, only prophylactic perioperative antibiotics are required postoperatively when there are not any complications of duodenal fistula. Oral intake can be started after routine gastrointestinal decompression and recovery of bowel functions. For patients whom undergone to subtotal cholecystectomy, postoperative high fever warrants attention to the possibility of bacteremia and postoperative cholangitis. Postoperative imaging should be considered for determining the biliary leakage or intra-abdominal fluid collections; and to assess the residual stones in remnant gallbladder or extrahepatic bile duct system. If residual gallstones are detected, endoscopic interventions have to be considered in extracting the stones from extrahepatic bile duct system; or secondary surgery to remove the remaining gallbladder for avoiding the recurrent attacks. From the two severe cases included in this study, we summarize that patients with poorly controlled diabetes, diabetic nephropathy, or having the history of long-term steroid use often present with malnutrition, impaired tissue healing, and compromised immunity process [39, 40]. Once a duodenal fistula develops, infection can rapidly become uncontrolled, and may lead to severe complications [41, 42]. In such high-risk patients, manual suturing and conversion to open surgery can be considered when the stapler closure is not technically possible particularly for laparoscopic approach. In addition, reinforcement with an omental patch should be performed, and double abdominal drainage tubes should be placed to allow the continuous lavage in reducing the damage of intestinal content in high risky patients whom may develop duodenal fistula.

There are multiple limitations to this study. First, it was a single-center retrospective study with a relatively small sample size, which may introduce selection bias. Second, cases with marked gallbladder wall atrophy were not suitable for stapler closure and therefore required manual suturing, which may lead to confounding by indication. Third, the accrual period spanned many years; although all procedures were performed by experienced hepatobiliary surgeons, improvements in laparoscopic equipment and instruments over time may have influenced operative outcomes. Finally, postoperative follow-up in this study focused primarily on intraoperative and short-term (within 90 days) outcomes, and long-term events such as biliary stricture, fistula recurrence, or malignant transformation were not systematically evaluated.Future large-scale, multicenter prospective randomized controlled trials are needed to further validate these findings.

Conclusion

The results of this study emphasize that stapler-assisted closure using the preserved gallbladder wall offers multiple advantages in the repair of cholecystoduodenal fistulas. This technique is easier to perform, significantly reduces operative time and the rate of intraoperative conversion to open surgery, and lowers the incidence of postoperative duodenal fistula and related complications. Therefore, it represents a safe, effective, and clinically applicable therapeutic strategy. However, in cases where the stapler use is inappropriate due to the technical issues; manual suturing can be the preferable method in selected cases.

Abbreviations

ASA

American society of anesthesiologists

BMI

Body mass index

CDF

Cholecystoduodenal fistula

CRP

C-reactive protein

CT

Computed tomography

ERCP

Endoscopic retrograde cholangiopancreatography

ICU

Intensive care unit

IQR

Interquartile range

MRI

Magnetic resonance imaging

PTGD

Percutaneous transhepatic gallbladder drainage

SD

Standard deviation

Authors’ contributions

All authors contributed to the study conception and design. Long Huang drafted the initial manuscript. Jianlin Lai and Dihang Wu performed statistical analysis and assisted with manuscript preparation. Xu Zhan collected clinical data. Shi Chen and Yifeng Tian critically revised the manuscript and supervised the study. All authors read and approved the final version of the manuscript.

Funding

This work was supported by the National Outstanding Young Physicians Talent Program to Shi Chen; Fujian Provincial Health Technology Project (2021GGA006) to Long Huang.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Fujian Provincial Hospital (K2025-09-011) and study was conducted under the guidance of the Declaration of Helsinki. All participants signed a written informed consent form.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.